Opioid treatment program culture and philosophy: Views of OTP staff and state officials on implementing interim methadone treatment

Abstract

Introduction:

People seeking treatment at opioid treatment programs (OTPs) can face admission delays. Interim methadone (IM) treatment, an effective approach to expedite admissions when programs lack sufficient counseling staff, has been seldom implemented. A study of implementation facilitation to spur the use of IM was conducted among six OTPs and their state opioid treatment authorities (SOTAs) in four US states. Between study recruitment and launch, organizational changes at three OTPs eliminated their need for IM. Two OTPs’ requests to their states to provide IM (one prior to study launch and one following launch) were deferred by the states due to internal issues that required resolution to comply with federal IM regulations. During the study, another OTP’s delays resolved, and one OTP streamlined its admissions procedures.

Methods:

Virtual interviews were conducted with 16 OTP staff and SOTAs from six OTPs in four US states following their participation in the parent study. Interviews focused on the feasibility and acceptability of the implementation intervention for IM. We analyzed data using a constant comparative approach.

Results:

Two overarching themes emerged from the qualitative data with respect to the role that organizational culture plays in OTP staff views of efforts to implement interim methadone: (1) the contrasting views of interim methadone based on whether staff adopt a traditional treatment vs. harm reduction philosophy and (2) the importance of reconciling these philosophies in addressing the culture shift that would accompany the process of implementing IM.

Conclusions:

Organizational treatment philosophy and program culture emerged as important factors determining the OTPs’ staff’s willingness to adopt new approaches to expedite admissions. Participants noted a tension between traditional treatment and harm reduction philosophies that impacted their views of IM, in part based on when they entered the drug treatment field. While understanding and addressing treatment philosophy and organizational culture and willingness to change is of importance when implementing new approaches in OTPs, leadership at the state and OTP level are powerful drivers of change.

1. Introduction

Three waves of the most recent US opioid epidemic have killed over a half a million people from 1999 through 2020 (Centers for Disease Control and Prevention (CDC), 2022). Throughout the first wave of increased prescribing of opioids, the second wave of increased use of potent heroin, and the current wave of illicitly produced fentanyl, many people with Opioid Use Disorder (OUD) have not received treatment (Substance Abuse and Mental Health Services Administration (SAMHSA), 2020; Wu et al., 2016). While much has been done to increase access to OUD treatment, including the expansion of federal funding, the availability of new medication formulations (e.g., buprenorphine, extended-release buprenorphine, and extended-release naltrexone), federal regulatory flexibility during the COVID pandemic, and the opening of new Opioid Treatment Programs (OTPs) (Congressional Budget Office, 2022; Pew Charitable Trusts, 2021; Vestal, 2018), some people seeking OTP admission experience long delays or are placed on waiting lists (Sigmon et al., 2016; Wiley, 2022). Because methadone treatment is associated with reduced risk of opioid overdose death and waiting for treatment can be deadly (Krawczyk et al., 2020; Peles et al., 2013; Sordo et al., 2017), it is of considerable importance to deploy ways to expedite OTP admissions.

OTPs have several options available to reduce waiting time for admission, including streamlining their admission process, hiring more counselors, or providing interim methadone maintenance (IM). Streamlining the admissions process, to the extent possible, can be useful (Hoffman et al., 2008) although limited by the availability of counseling and medical staff. IM, approved for use in the US in 1993, can be an effective approach to reduce waiting time when delays are due to a lack of sufficient counselors (McCarty et al., 2021). IM refers to providing methadone treatment without counseling to individuals seeking OTP admission who would otherwise not be admitted within 14 days of request due to insufficient availability of counselors (Code of Federal Regulations, 2001). However, the adoption of IM can involve a time-consuming process of attempting to overcome federal and state regulatory barriers. To provide IM, federal regulations require OTPs to obtain approval of their state health authority and SAMHSA. Take-home doses (even on Sundays) are not permitted, and it can be provided for only 120 days prior to transferring the patient to what the federal regulations term “comprehensive maintenance treatment” which includes counseling (Substance Abuse and Mental Health Services Administration (SAMHSA), 2015). Additionally, its use is restricted to non-profit and government programs.

Although, IM has been shown in clinical trials to be more effective than waiting list placement in successfully admitting people to comprehensive treatment and reducing illicit opioid use (Schwartz et al., 2006; Yancovitz et al., 1991), it has rarely been implemented outside of research studies (McCarty et al., 2021). Given the association between being out-of-treatment and opioid overdose death (Krawczyk et al, 2020; Sordo et al., 2017), it is of considerable importance to discover and overcome barriers to treatment entry (Cioe et al., 2020; Rieckmann et al., 2007).

Organizational culture, that is a pattern of shared meanings, assumptions, attitudes, and values that drive an organization’s practice, (Schein, 2004) can also serve as a barrier to implementing new services and treatment entry. Organizational cultural has been found to play a role in how long Black and Latino people wait for admission to OTPs (Guerrero & Andrews, 2011) and whether OTPs implement Hepatitis C treatment (Treloar et al., 2010). In terms of methadone treatment, traditional views of treatment and OTP organizational culture assume that counseling is a necessary component of OTP treatment and abstinence is the goal (Kang et al., 1998; O’Hare, 2007; Stewart et al., 2021). Methadone can also be conceptualized as harm reduction, in which the focus typically emphasizes overdose prevention and reduction of unhealthy opioid use, injection, and needle sharing, rather than solely focusing on abstinence (Buning et al., 1990; O’Hare, 2007). In the context of IM, the latter serves as an alternative to unremitting illicit opioid use among people awaiting admission to methadone treatment with counseling (Buning et al., 1990) and thus, IM can be considered both treatment and harm reduction. To our knowledge, the role that organizational culture plays in implementing IM has not been studied.

The purpose of this qualitative study is to examine the role that treatment philosophy and organizational culture played during a study which sought to implement IM and other approaches to reduce admission waiting time for admissions in six Opioid Treatment Programs in the US.

2. Methods

2.1. Parent Study

The parent study examined the use of implementation facilitation to spur the adoption of IM and other ways to reduce the time between an individual’s request for OTP admission and their initiating treatment (ClinicalTrials.gov, 2023). Implementation facilitation included the use of an external technical expert in interim methadone as the facilitator who provided on site and virtual technical assistance to the study OTPs. Six OTPs on the east and west coasts of the US reporting an inability to admit patients within 14 days of request, and their respective State Opioid Treatment Authority (SOTA), participated in the trial. Using a modified step-wedge design, the study randomly assigned two groups of three OTPs to the order in which they began the implementation intervention phase. Following recruitment to the study but prior to study launch, one OTP applied to use IM. That OTP and one other, moved to same day admissions and a third OTP hired additional medical and counseling staff, thus eliminating their admission delays. During the study, a fourth OTP began the process of streamlining its admission procedures, and a fifth applied to use IM. The states’ approvals of the two IM applications were deferred while they addressed internal regulatory issues that required resolution to accommodate federal requirements. In one case, the state needed to update its OTP reporting data system to accommodate federal regulatory IM reporting requirements and in the other case the state had to reconcile which part of the state government was responsible for complying with the federal regulations. A sixth OTP no longer had delays. The Western Institutional Review Board (WIRB) approved the study.

2.2. Qualitative Methods

From October 2020 through July 2021, the study conducted 16 qualitative interviews with the SOTAs and OTP staff. All participants took part in the intervention to implement IM. Prior to being invited to complete the interviews, participants were given copies of the WIRB-approved information materials about the study. The study obtained verbal informed consent from all participants prior to the start of the interview and after background of the study was provided. The study conducted the interviews after the participating clinics’ implementation phase in the original parent study ended. Half of the interviews were gathered in fall 2020 and we conducted the other half in summer 2021. The study did not provide financial compensation to participants for taking part in the interviews.

2.3. Participants

The study had 16 participants including SOTA and OTP staff who were directly involved in the implementation facilitation intervention of the parent study. OTP staff participants were comprised of OTP leadership (program directors and clinical directors) and intake staff. All participants identified as White and were mostly non-Hispanic (n=15/16) and female (n=10/16).

2.4. Interviews

All interviews were conducted via Zoom and lasted, on average, 60 minutes. The study tailored the semi-structured interview guide to each type of respondent (i.e., SOTA or OTP staff) and focused on the feasibility and acceptability of the implementation intervention for interim methadone. An example of feasibility questions from the SOTA interview guide included “How easy were the activities you conducted in your work implementing interim methadone in your state?” and “What assistance did you receive during the study that you found helpful in making progress with interim methadone implementation?” Acceptability questions from the SOTA interview guide included “What do you think the benefits of implementing interim methadone were?” as well as asking about the drawbacks of implementing the intervention. The interview guide for the OTP staff also included feasibility and acceptability questions. Examples of feasibility questions for the OTP staff were “How easy were the activities you conducted in your work implementing interim methadone in your clinic?” and “What would you tell other OTP clinic directors considering implementing interim methadone?” The acceptability questions for the OTP interview guide also asked about the benefits and drawbacks of implementing interim methadone as well as “What can you do to help prepare your staff for the delivery of interim methadone; should it be necessary due to waiting lists or excessive treatment delays?” (See Supplemental Table for full interview guide.)

2.5. Analysis

All virtual interviews were audio recorded and subsequently transcribed, reviewed for accuracy, and loaded into ATLAS.ti software (Version 8.4) for analysis (ATLASTI.com, 2022). Two of the authors (SGM and KBC) used Grounded Theory as an emergent qualitative research approach to their analysis to reveal themes related to organizational culture. The study selected grounded theory because it is an inductive approach to analyzing data to develop the data-derived codes, categories, and themes (Charmaz, 2008). The current study used a constant comparative method in which the coding scheme for data-derived codes and categories, which later determined themes, was created after reading the first five transcripts and was then applied to all remaining transcripts in an iterative process. Initial codes were created after discovering incidents in the data and comparing incidents to one another. We created categories by collapsing the initial codes while the iterative process of comparing incidents across codes and categories continued (Birks & Mills, 2015; Glaser & Strauss, 1967).

3. Results

Two overarching themes emerged from the data of participants’ views with respect to the role that OTP’s organizational culture would play in efforts to implement IM: (1) the contrasting views of IM based on whether staff adopt a traditional treatment vs. harm reduction philosophy and (2) the importance of reconciling these philosophies in addressing the culture shift that would accompany the process of implementing IM.

3.1. Traditional vs. harm reduction view of OTP treatment

Participant descriptions of staff views on implementing IM revealed the tension between staff’s traditional approach and perceptions of IM as a form of harm reduction. One aspect of the traditional approach included some staff believing that people seeking treatment need to demonstrate their motivation by repeatedly calling for an intake appointment over several days. This contrasts with the harm reduction approach of IM in reducing barriers to treatment admission, even if it meant delaying access to counseling.

Several staff at one clinic reported that policies and procedures at the start of the study were so stringent for patient access to services that, if they were in the patient’s position, they would not seek admission at the program. For example, the following policy was discontinued during the study.

When I started it was based on this arbitrary point system where people would come in for screening and be asked to call once weekly and for every week that they called they would get a point. And that was some of the, this older, I shouldn’t say older, but classical thinking of ‘people need to be willing and ready and going to whatever lengths necessary to get help for the dependency’… I would go somewhere else [for treatment]; no one on earth is going to do that. So why are we putting people who are most vulnerable through this tumultuous process?

Intake Staff 1

A second characteristic of the traditional OTP culture concerns the importance of counseling in the treatment. This perspective may be associated with the fact that counseling was a required component of methadone treatment since its inception in the US and caseloads were limited in the federal OTP regulation, until its revision in 1990, by a patient to counselor ratio of 50:1 (Institute of Medicine (IOM), 1995). Interim methadone, which some staff considered a harm reduction approach, is grounded in the belief and empirical evidence that medication alone is better than not being able to provide comprehensive treatment at all (Schwartz et al., 2006; Yancovitz et al., 1991). Some participants indicated that when fellow clinic staff recognized that interim methadone violated these aspects of traditional treatment, they responded negatively to its implementation. For some OTP staff, a traditional approach meant upholding current strict values because that was the way it had always been done.

One SOTA shared the experience of discussing the implementation of IM within their state. This participant noted that because of the OTPs’ traditional views, its implementation, even temporarily, would be difficult.

It’s so surprising that it’s never been requested… I don’t know if there’s almost like philosophies like we don’t want to provide medication without the counseling because I have noticed from the OTPs… they [OTPs] said “you need to have counseling, you need to have counseling.” So, I feel like there’s almost like, that belief, because for so long the OTPs, they provide all those services, and they don’t believe in medication alone to get started.

SOTA 1

The feelings of caution, hesitancy, and even resistance to implementing IM were reported as common across the state, as indicated by another SOTA’s comments about trying to adopt IM prior to the present study as an emergency response when a methadone program closed in the community, thus reducing treatment availability.

I got a lot of push-back from programs that didn’t want it [IM]. And they just didn’t feel comfortable. They didn’t quite understand it. They thought it was diminishing the OTP capacity for delivering comprehensive care. They felt that there were more vulnerabilities. And it was hard in that emergent situation [program closure] to try to move the needle.

SOTA 2

When the SOTA later brought the idea of IM back to the OTPs for this study, the SOTA was still met with resistance from some OTP leadership. This SOTA pointed out that even though many of the OTPs approached about study participation were near or at capacity, some clinic leaders were still opposed to IM:

They didn’t understand why we were asking them to do it. They didn’t know why it was a good idea because they felt that the treatment [counseling] was a necessity. So, I think there does need to be education.

SOTA 2

However, as noted by the following participant, in some cases the idea of implementing IM was met with more enthusiasm by OTP staff, particularly when they embraced a more harm reduction approach to treatment, as illustrated by the following quote from clinic leadership.

Some individuals see it as, I don’t want to call it cutting corners, because it’s not, it’s giving quicker access to care. And I think for some perspectives there’s hesitation…But I think there’s a value difference when it comes to harm reduction and access and critical compliance and wrap around services etcetera, I think there’s an in between…I think you see the divide in the terms of the staff. They’re like super excited about this and it’s really groundbreaking stuff and others that are a bit more hesitant or leery…Well from location to location and staff to staff we have some folks that are more in the harm reduction access to care no matter what and there’s less hesitation versus others that it’s that very strict, we have to do it the way we’ve always done it, this is the safe way, there’s no other way.

Clinic Leader 1

Multiple participants noted that IM was seen as a harm reduction orientation. One OTP participant described these staff differences in terms of how older staff members tended to adhere to more of a traditional treatment philosophy whereas newer and younger staff members were likely to endorse the harm reduction perspective, producing a “culture clash” in the program.

There is definitely kind of [a] culture clash between people who came up in substance treatment world, kind of a more classic perspective, non-harm reduction, more of an abstinence only, and then newer graduates and people coming out of school with a harm reduction training and excitement. And so I think as supervisors in the [context of] interim [are] really getting these teams to work together and communicate and see the value in finding some common ground and hopefully being driven more by the harm reduction part and less by the abstinence only and/or just demand for some perfection from patients versus this is treatment; they’re coming here and they’re going to be using other drugs, okay well then let’s treat everything we can and get them support and help and care.

Clinic Leader 2

At one clinic, a couple of OTP staff expressed concerns about implementing IM due to the anticipated negative responses from patients. They conjectured that patients who were admitted through comprehensive treatment with required counseling might become agitated while interacting with IM patients. In the words of one clinic staff member, the IM patients might say “I can just get my dose. I don’t have to do anything. I’m not doing any work. I’m just getting methadone” (Intake Staff 2).

Another clinic staff member saw IM as potentially contributing to patients not wanting to attend counseling sessions following the admission to comprehensive methadone treatment.

We really do struggle in getting these patients to engage with their counselor, even in normal everyday situations. But then you bring somebody into interim and even though you’re very clear about what this program is versus what if they do a formal admission to the program, what that looks like it is still very, very difficult to get them to engage. So, your engagement rates are probably going to be a bit lower [in] this population, which is again it’s like you’re constantly chasing people, it can be very, very difficult. That would be my only criticism of it, otherwise I completely am behind people getting on medication even without therapy.

Clinic Leader 3

The divide between traditional methadone treatment and harm reduction approaches was further explained by one participant who equated implementing IM to more than changing policies and procedures. By having the clinic adopt IM and initiate methadone prior to counseling, the participant felt the OTP was switching to a medical model, rather than focusing on rehabilitation and recovery. This change would indicate a profound organizational shift in the OTP as exemplified by the following:

It’s like it’s a huge shift that we’re shifting to medical, we’re more of a medical model and away from a treatment model, like addiction treatment model to a more medical model…in addition to the harm reduction approach.

Clinic Leader 4

3.2. Cultural and organizational change

When the Implementation Facilitator presented IM to the staff, respondents described various reactions from their fellow staff members. Some OTP staff noted that organizational change associated with implementing IM would be difficult where hurdles to patient access to services were engrained in the organizational culture. As one participant noted, introducing new ideas was difficult because of mindsets: “It was very much a culture shift for this staff, very, very much…and I think we have 45 odd staff, and many are old school, so shifting ideas about these things is really, really hard” (Clinic Leader 5).

Voicing a different perspective on the intervention, one respondent in a supervisory role talked about more positive reactions to IM: “So I think it got me really encouraged, excited about what’s possible” (Clinic Leader 2). A statement from a treatment entry team member summed it up best: “I just think any sort of change might be difficult for staff at first, but I don’t think it’s insurmountable” (Intake Staff 1).

Another program participant talked about how some staff members were hesitant to implement IM because it would create more work. This participant noted that “it’s still not very popular in medical department because the medical department feels that they’re taking all the responsibility. Who’s going to manage the case? Who’s going to answer questions? Who’s going to do some of the case management?” (Clinic Leader 6).

For those staff members who responded with fear, they stated that implementing IM would cause current staff members to lose status and purpose within the clinic, as illustrated by Clinic Leader 4 who stated that discussing IM with the staff has been difficult because more established counselors “feel like they’re losing status…that we’re saying somehow that counseling is not necessary” even though that is not the purpose of IM.

Others saw IM implementation as too far afield from the current standard operating procedures and thus expressed resistance to change. One clinic participant mentioned that staff at their organization were reluctant to implement IM because it was something they had not used before.

I think there might be some resistance to implementing interim dosing on some level because it’s new and it’s different and it seems like it would be chaotic, right? And so, I think that might be something that our supervisor is thinking about is like how to frame this in a way that doesn’t seem more stressful to the staff as a whole.

Intake Staff 1

Some OTP staff found that participating in the study spurred introspection regarding other cultural and organizational changes that needed to be made before implementing IM. For one clinic leader, this introspection led the OTP staff to question their thinking about the ultimate acceptability of having a waitlist.

And then I think equally as important was one of the philosophical shifts from maybe the ideal of people being on a wait list was an okay thing to note the more urgency if we want to get people in, get them in faster that that would be the metric that would help the team feel like there was success. And then more discussions around what does it mean to actually be on a wait list…we would be engaging with them, but they were still on the wait list, still unmedicated, still waiting for care. And so, the conversations I felt like I was involved with people were shifting their mindset to be more I guess a little more empathetic or sympathetic to what it feels like to be waiting on a wait list…Basically, what are we doing if we’re not bringing them in? Well, we’re making them wait, they’re suffering. We have this medicine that they qualify for that they should have access to.

Clinic Leader 2

For the following staff member, better patient care began with improving initial access to services. Their mission was to improve policies and practices to be able to serve patients that are seeking care.

It boiled down to just the simple fact that turning people away was not an option for us, any of us, it doesn’t matter if it was management, administrative, clinical, medical, any of that, it was just not an option. Or telling them, ‘I’m sorry we want to offer you services but you’re going to have to come back. We’ll schedule you in two to six weeks.’ When you work in a substance use field you know that when someone’s ready, they’re ready right now.

Clinic Leader 5

As noted by Intake Staff 2, IM is an intervention to stabilize the patient and relieve pain while waiting for other clinical care. It is a form of triaging the most immediate health needs so that the patient is better able to manage therapy and other supports: “We’re giving them medication to stop the pain to make the client more focused and then we’re moving on to the next step.”

Participants, both at the OTP and SOTA levels, from different states noted that from a state level, IM would be accepted. One OTP staff mentioned that it was in line with the state accrediting system, which resulted in the program feeling supported. Some participants greeted the study with interest because creating IM policies and procedures would give them an opportunity to create a solid contingency plan to use during a public health emergency or environmental crisis when resources for comprehensive treatment procedures might be limited. The following participant summarized staff experiences by explaining how IM can be useful in emergencies, and pointing out that once organizational culture was addressed, implementation of interim methadone was not difficult.

I would just say that there was no reason that you wouldn’t do it. I would say that it gives a piece of mind for again like for knowing that you have tools to help you if you’re in an emergency, short staffed or an actual physical emergency where you’re needing to potentially assist other OTPs…It’s really easy. Well, okay, after I said all that stuff about culture shifts, that did take a long time to get into place, however once that was done the policies and the procedures are not difficult to get implemented.

Clinic Leader 4

4. Discussion

Learning about OTP providers’ views of treatment can inform ways to increase access to care to address the opioid epidemic (Cioe et al., 2020; Rieckmann et al., 2007). This qualitative study examined the views of 16 staff from six OTPs and their respective four SOTAs who were engaged in a study to implement interim methadone treatment and other approaches to reduce admission delays. During these interviews, organizational treatment philosophy and program culture emerged as important factors determining the willingness of OTP staff to adopt new treatment approaches to expedite the admission process.

SOTAs and OTP staff noted a tension between traditional treatment and harm reduction philosophies that impacted their views of IM. This philosophical difference was seen as the result of a divide in which newer graduates were inclined to support harm reduction and longer-standing staff were inclined to uphold traditional treatment practices. Such tension and divide were also noted in other studies in the US and in Ireland (Cioe et al., 2020; Peter et al., 2022).

The traditional philosophy was manifested in the belief of some staff that people seeking care should be required to demonstrate their motivation by calling the program on a regular basis to check their waiting list status rather than be admitted through a low threshold barrier to care. In addition, the traditional philosophy viewed counseling as an essential element of treatment and hence had reservations of interim treatment, which is provided without counseling, in lieu of delayed admission.

Traditional views of treatment and OTP organizational culture assume that counseling is a necessary component of OTP treatment (Kang et al., 1998; Stewart et al., 2021). In the US, counseling has been a required part of standard methadone treatment since the first US federal regulations were approved in 1972 (Institute of Medicine (IOM), 1995), whereas outside the US, methadone treatment is often provided by physicians in primary care offices without additional counseling required (Buresh et al., 2021; Gossop et al., 2003; Weinrich & Stuart, 2000). While several participants considered IM treatment within the harm reduction realm, others considered it simply OUD treatment (Friedmann & Schwartz, 2012).

Interest in methadone without counseling to facilitate admission was first reported over 50 years ago (Severo, 1970). Following the initial demonstration of the effectiveness of IM in New York City by Yancovitz & colleagues (1991), the Food and Drug Administration and the National Institute on Drug Abuse jointly proposed incorporating IM into the federal OTP regulations to reduce the spread of HIV among people who inject heroin (Associated Press, 1989). Despite the support of Vincent Dole, the co-founder of methadone treatment (Dole, 1991), after considerable resistance from the field in public hearings and comments, the proposal was withdrawn (The New York Times, 1990). IM was subsequently approved as part of the revised OTP regulations during the creation of SAMHSA (Institute of Medicine (IOM), 1995). Although it has been rarely implemented since then outside of the research context (Schwartz et al., 2006; Schwartz et al., 2009; Schwartz et al., 2011), it now has the support of the American Association for the Treatment of Opioid Dependence (American Association for the Treatment of Opioid Dependence, 2022). Indeed, lowering barriers to treatment entry to increase the percentage of people with OUD in effective treatment is currently considered an important approach to address the opioid epidemic because enrollment in methadone treatment is associated with reduced risk of opioid overdose death (American Association for the Treatment of Opioid Dependence, 2022; Associated Press, 1989; Krawczyk et al., 2020; Peles et al., 2013; Sordo et al., 2017).

Program orientation, leadership, and culture are also thought to play an important role in the effectiveness of substance use disorder treatment programs (Ball & Ross, 2012; Hilton et al., 2002; Peter et al., 2022). In a study of barriers to implementing medications for OUD in treatment programs in Philadelphia, leaders reported championing a culture shift and change of perspective among their staff (Stewart et al., 2021). In the current study, OTP leadership who signed onto the study, were faced with contrasting perspectives among their staff. Some OTP staff mentioned concern regarding increased workload, loss of status that might accompany implementation of IM, or providing less than comprehensive care to their newly admitted patients. In contrast, others expressed concern for people who are seeking, but unable to access, care. Approaches to reconcile these views through staff education, narrative messages, incorporating systems that foster staff communication and collaboration, and reducing staff turnover are warranted (Andrews et al., 2005; Stewart et al., 2021).

Several federal and state initiatives are underway to change organizational practices to increase access to care. SAMHSA is currently revising its OTP regulations and considering allowing greater flexibility related to its IM provisions (Federal Register, 2022). States are increasingly implementing low-threshold medication treatment for OUD to remove admission barriers (Winograd et al., 2020). These, and other approaches to increasing access to methadone treatment for people with OUD, seek to address the nation’s opioid epidemic (Aronowitz et al., 2022).

Leadership at the state and OTP level can be powerful drivers of change. All SOTAs and OTP Directors in the study agreed to participate in the study. All the OTPs developed policies and procedures to implement IM. Underscoring the importance of leadership, three of the six OTPs in the study were able to eliminate their program’s admission delays during what can be considered the EPIS implementation framework’s exploration and preparation phases (Aarons et al., 2011); that is, following recruitment but prior to study launch. During the study, another OTP was in the process of making changes to its admission process to streamline and hasten admissions.

Although two OTPs’ requests to use interim methadone were deferred (one prior to and one during the study), this experience demonstrated their directors’ willingness to use it. Two different barriers to comply with federal IM regulations existed at the state levels. Prior to the study’s launch, one state had a need to determine internally who could represent the state as the “public health officer” mentioned in the regulations. This issue was subsequently resolved by SAMHSA during the study, by indicating that the SOTA could serve in that capacity. This determination has been included in the proposed new federal IM regulations (Federal Register, 2022). In another state following study launch, the state needed to update its data system to comply with the federal regulatory requirement that OTPs inform the state of new IM admissions and transfers to standard methadone treatment.

Although all OTP staff contribute to the culture of the program, ultimately, program leadership decides its treatment philosophy and develops policies and procedures that reflect it. SAMHSA and SOTAs can play an important role in supporting the understanding, approval, and implementation of IM when needed by providing education, technical assistance, and regulatory guidance. OTP Directors can play an important role by working closely with their SOTAs and staff to provide education and address misconceptions and philosophical differences among their staff by emphasizing that IM serves as an effective alternative to no treatment, is a gateway to comprehensive treatment, and is useful as an overdose prevention tool.

This study had several limitations. We conducted the study with 16 staff from six non-profit and governmental OTPs on the east and west coasts of the US. Hence, findings may not generalize to for-profit programs and other geographic areas. In addition, views of staff not directly involved in the implementation facilitation intervention and people requesting treatment were not obtained. The study completed no pre-implementation interviews. Although this article discusses philosophical differences as an issue of when staff entered the field, based on our knowledge of the states, other factors are likely influencing views on adoption of harm reduction approaches. Some states are more supportive of these approaches than others. IM is an approach that can align with either harm reduction or traditional treatment philosophies. Other potential factors that are not captured in this paper include Medicaid funding and workforce issues.

The information garnered from the current study highlights the importance of understanding organizational culture while trying to create a change friendly environment during implementation of new programs. The history of IM outlined above shows that change is possible, albeit at a slow pace. Further direct and explicit support from SAMHSA and state officials through technical, regulatory, and financial support to quickly implement interim treatment when needed would be warranted.

Highlights.

• Interim methadone maintenance treatment (IM) without required counseling is an effective alternative to waiting lists or admission delays and is included in the federal opioid treatment program regulations; albeit with a variety of limitations

• 16 OTP staff and four State Opioid Treatment Authorities participating in a study of using implementation facilitation to prompt the use of IM were interviewed about their views of the feasibility and acceptability of the intervention.

• OTP treatment philosophy and organizational culture play an important role in efforts to implement IM.

• Understanding treatment philosophy and organizational culture is of considerable importance during efforts to implement new treatment approaches in OTPs.

Availability of data and materials

De-identified datasets created and/or analyzed during the current study in preparation for this manuscript can be made available upon reasonable request from the corresponding author.